10 STORY ST - BPA-13-505 �J The Commonwealth of Massachusetts
OF
Board of Building Regulations and Standards CITY SALEM
Massachusetts State Building Code, 780 CMR dMar
Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Dar Ap ied:
"Building Official(Print Name) " Sirmatur Date
SECTION 1:SITE INFOItMAT16N
1.1 P�perry ��ss: /fir£ 1.2 Assessors Map&Parcel Numbers
Ll a Is this an accepted street?yes ✓ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.u.L c.40,§54) 1.7 flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑
Check if yesO
.SECTION 2 PROPERTY OWNERSHIP'
II, 2.1Owner' Record:
Name(Print) City,State,ZIP
zo S1D.eY� z
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition [IAccessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work-2: _ 7
— lNs�QI�
t"5 N
c
SECTION t-ESTIMATED CONSTRUC ONO CSTS -
Item Estimated Costs: Official Use Only - -
Labor and Materials
1.Building $ 1. Building Permit Fee: $ Indicate how fee is determined::
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Costa(Item 6)xlmultiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List: ..
i
5.Mechanical (Fire $
Su ression Total All Fees: $
Check No: Check Amount: :Cash Amount:
6.Total Project Cost: $ i 0 Paid in Full 0 Outstanding Balance Due: `
SECTION 5: .CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
��i -09�935 .3 as a /y
�A&/1—/ /-�' LZ//V/1 L/� License Number Expiration Date
Name of CSL Holder '
List CSL Type(see below)
a�9 /���aoh' ,��
No.and Street Type, Description
�('y Unrestricted(Buildings u to 35,000 cu_ft.
nw �'#- ,/n /?"2 Restricted 1&2 Family Dwellin
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
1W S 2-150 c/f1/'QImOL.D I Insulation
Telephone Email address -Coll D Demolition
5.2 Registered Home Improvement Contractor(HIC) 1S7 p/(�
�1JL//V 49t /-/' /l�//VO HIC Registration Number xpiraH t
HIC Company Name or HIC Registrant Naipe ,
C 2 z/
No. d Street Email ad&css
N ( o- sriy
City/Town',State,ZIP Telephone
SECTION 6:WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152. § 25C(6)) s+t�
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes .......... uo� No........... ❑
SECTION 7a::OWNERAUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT.:OR CONTRACTOR APPLIESYOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize ,Q/ P/M ZI
to act on my behalf,in all matters relative to work authorized by this building perindapplication.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNER'OR"AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A. Other important information on the HIC Program can be found at
www.mass.eov/oca Information on the Construction Supervisor License can be found at w�vw.mass.gov/dps
27 When substantial work is planned,provide the information below:
Total floor area(sq. ft.) (including garage,finished basement/attics,decks or porch)
Gross living area(sq. ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
CITY OF S:ULE:,I, i.L1SS:ICHUSETTS
s BUILDING DBPART.NIEINT
'c�r 120 \' ASNLINGTON STREET, 311D FLOOR
bae T EL (978) 745-9595
F.A_e(978) 740-98•ib
IC\IBERLEY DRISCOLL
MAYORTrIObfAS ST.PtEQRB
DIRECTOR OF PUBLIC PRO PERTY/BUIIDIIVG COSaIISSION ER
Workers' Compensation Insurance Affidavit: Builders/Contractorv/Electricians/Plumbers
Almlicant information Please Print Legibly
Name(Busiii%N&Otgtnizatioruindividual):
Address:l— y '�A\ i`r*City/State/Zip:S 'i,-Jz%-f, S Q \ 1 Phone hl: i In C) o S y
Are you an employer?Cheek the appropriate box: 'type of project(required):
1.0 1 am a employer with 4. 0 I am a general contractor and 1 6. ❑New construction
employees(flull and/or part-time).* have hired the subcontractors
2.OZI am a solo proprietor or punrrrs-
listed on the attached sheet t 7. ❑Remodeling
ship and have no employees These sub-contractors have V. ❑ Demolition
Workingfor me in an capacity. workers'comp.Insurance.
Y P h'• 9. E] Building addition
(No workers comp. insurance 5. 0 We are a corporation and its
required.) officers have exercised their 10.E]Electrical repairs or additions
3.0 1 am a homeowner doing all work right of exemption per MGL I i.0 Plumbing repairs or additions
myself.(No workers'comp. c. 152,§1(4),and we have no 12.0 Roof repairs
insurance required.]t employees.We workers' I}.QOlher
comp.insurance required..*
•Any appllcum that checkoar g b rt must alto 611 uw The uctioo below showing theft workers'compenudon policy inlurmallon.
t I(rwuuwncm who suimait this aftldnvit indicating They am doing all w°rk mad then him""side contracts,maul submit a now altidavil indicating soda.
�Cmtmcton that Omit This box mat attached ant additlursJ shmi showing the numo of the suliw'tlrelao'm and that,worker'comp.policy infamution.
lain ors employer that is pruv/d/nl f lvorkers'car»prnsadan lusurrrncs jot toy ampluyerx Below Is lbe Polley uad Job sill
injorinulion,
Insurance Company Name:
Policy 4 or Self-ins. Lic, it: Expiration Date-
Job Site Address: City/State/Zip:
,kttacts a copy of the workers'compensation policy declaration pggg(showing the policy number and expiration data).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
line up to S 1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a line
of up to S25o.00 a day against the violator. Be advised that a copy of this statement may be furwarded to the Off ice of
Invusligmions of the MA fur insurance coverage verification.
/dulrrrrb ddrdtepulns penal prr/uryr/mrrheiajuronuNonprovided above i'siru1mrdcorrreR
ilsn nrr. - Data!
OJJiciul use onl),. Do not tvtile in thli urea,to be cuutpleled by city ur lawn n/J)rtu!
CitynrTown: _ Permit/f.lceme# j
IssuingAuiltority(circleone): -- -__----_—
I. Board of lleallh 2. Building Departutent 3.City/rown Clerk 4. Electrical inspector 5. Plumbing Inspector
6.Olher
Contact Person: __ --..- -- Phone 4:
i
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979534/NC3822 CVT 8/98 carbonlessetlentr NC3822 3 PART
CONTRACTORS INVOICE
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WORK PERFORMED AT: `3-77
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DATE - YOUR WORK ORDER NO. - " OUR BID NO. '
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All i aterial is guaranteed to be as specified, and the above work was perfo d in accordance with the drawings and specifications
provi r the above work a as co feted in a substantial workmanlike m er for the agreed su f
ollars ($
This is a 0 Partial ❑ Full invoice due and payable by:
e7953aNc3e22 gvT 8/98 Cdrbonless ''gym` NC3822 3 PART
CONTRACTORS INVOICE
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WORK PERFORMED AT:
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DATE YOUR WORK.ORDER NO. _ „__ OUR BID NO. .
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4�/61 — .300
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All Material is guaranteed to be as specified, and the above work was performed in accordance with the drawings and specifications
provided for the above work and was completed in a substantial workmanlike manner for the agreed sum of
Dollars ($ ).
This is a O Partial ❑ Full invoice due and payable by:
Month Day Year
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